ARTÍCULOS DE INVESTIGACIÓN CLÍNICA O EXPERIMENTAL

Effectiveness of Chlorhexidine
and Essential Oils Associated
with Scaling and Root Planing
in the Treatment of Chronic
Periodontitis
Efectividad de la clorhexidina
y aceites esenciales asociados
al raspado y alisado radicular
en el tratamiento de periodontitis crónica
Efetividade da clorexidina e aceites essenciais
associados à raspagem e alisamento radicular
no tratamento de periodontite crónica
Jhair Alexander León Rodríguez1,2
Sandra Thays Vargas Casana1,3
Pablo Alejandro Millones Gómez, DDS4*

Received: January 21, 2020 · Accepted: July 24, 2020

Doi: https://doi.org/10.12804/revistas.urosario.edu.co/revsalud/a.9795
To cite this article: León Rodríguez JA, Vargas Casana ST, Millones Gómez PA. Effectiveness of Chlorhexidine and Essential Oils
Associated with Scaling and Root Planing in the Treatment of Chronic Periodontitis. Rev Cienc Salud. 2020;18(3):1-11. https://doi.
org/10.12804/revistas.urosario.edu.co/revsalud/a.9795

Abstract
Introduction: Adjunctive treatment for periodontal disease is quite varied and depends on many factors.
This study aims to compare the effectiveness of 0.12% chlorhexidine and essential oils associated with
scaling and root planing in the treatment of chronic periodontitis. Material and methods: The sample
included 42 patients randomly assigned to three groups. Decrease in periodontal status was measured
with the World Health Organization’s periodontal probe by analyzing probe depth values a
​ nd level of
clinical insertion at 3, 4, and 5 months. Statistical analysis of the progress of the three therapies was
conducted using Student’s t, Anova, and Tukey tests with a significance level of p < 0.05. Results: The

1 Universidad Católica de Trujillo (Perú).

2 orcid: https://orcid.org/0000-0001-6382-7126

3 orcid: https://orcid.org/0000-0003-0714-8983

4 Universidad Privada de Huancayo Franklin Roosevelt (Perú).

* Corresponding author: pablodent@hotmail.com orcid: https://orcid.org/0000-0002-7105-0940

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 Effectiveness of Chlorhexidine and Essential Oils Associated with Scaling and Root Planing

obtained values demonstrated that 0.12% chlorhexidine is more effective in all of its follow ups, whereas
no significant difference existed between essential oils and the control group. A significant difference
was observed over time in each separate treatment. Conclusion: Chlorhexidine at a 0.12% concentration
associated with root scaling and planing is better than essential oil therapies for the treatment of chronic
periodontitis.

Keywords: Chlorhexidine; essential oils; mouthwash; chronic periodontitis.

Resumen
Introducción: el tratamiento coadyuvante de la enfermedad periodontal es muy variado y depende de
muchos factores. El objetivo del presente artículo fue comparar la efectividad entre clorhexidina al
0.12 % y aceites esenciales asociados al raspado y alisado radicular en el tratamiento de periodonti-
tis crónica. Materiales y métodos: la muestra estuvo conformada por 42 pacientes distribuidos aleato-
riamente en 3 grupos. La disminución del estado periodontal se midió con la sonda periodontal de la
Organización Mundial de la Salud, analizando los valores profundidad al sondaje y el nivel de inserción
clínica a los 3, 4 y 5 meses. Para el análisis estadístico de la evolución de las 3 terapias se empleó la t de
Student, análisis de varianza y test de Tukey con un nivel de significancia de p < 0.05. Resultados: los
valores obtenidos demostraron que la clorhexidina al 0.12 % es más efectiva en todos sus controles;
mientras que no existe diferencia significativa entre aceites esenciales y el grupo control. Existe dife-
rencia significativa a través del tiempo en cada tratamiento por separado. Conclusión: la clorhexidina al
0.12 % asociada al raspado y alisado radicular es superior a los tratamientos con aceites esenciales en el
tratamiento de la periodontitis crónica.

Palabras clave: clorhexidina; aceites esenciales; enjuague bucal; periodontitis crónica.

Resumo
Introdução: o tratamento coadjuvante da doença periodontal é muito variado e depende de muitos fato-
res. O objetivo do presente estudo foi comprar a efetividade entre clorexidina ao 0.12% e aceites essen-
ciais associados à raspagem e alisamento radicular no tratamento de periodontite crónica. Materiais
e métodos: a amostra esteve conformada por 42 pacientes distribuídos aleatoriamente em 3 grupos.
A diminuição de estado periodontal se mediu com a sonda periodontal as Organização Mundial da Saúde
analisando os valores profundidade à sondagem e nível de inserção clínica aos 3, 4 e 5 meses. A análise
estatística da evolução das 3 terapias, se realizou empregando t de Student, Anova e teste de Tukey com
um nível de significância de p < 0.05. Resultados: os valores obtidos demostraram que a clorexidina ao
0.12% é mais efetiva em todos seus controles, enquanto não existe diferença significativa entre aceites
essenciais e o grupo controle. Existe diferença significativa através do tempo em cada tratamento por
separado. Conclusão: a clorexidina ao 0.12% associada à raspagem e alisamento radicular é superior aos
tratamentos com aceites essenciais no tratamento da periodontite crónica.

Palavras-chave: clorexidina; aceites essenciais; enxaguante bucal; periodontite crónica.

Introduction

P eriodontitis is an infectious pathology whose main characteristic is the formation of peri-

odontal pockets or gingival recession, which is caused by inflammation and destruction
of the supporting and surrounding dental structure (1-3). Severe periodontitis causes tooth
loss and is very common; it is prevalent in 10% of the population worldwide (4).

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 Effectiveness of Chlorhexidine and Essential Oils Associated with Scaling and Root Planing

Literature consistently states the importance of supragingival plaque control due to

its positive effect on periodontal disease, which has been demonstrated for a long time.
Mechanical plaque control is the most common form of oral hygiene; however, individual
mechanical control has limitations, especially in terms of skill and motivation (5,6).
Several substances such as natural products, systemic antibiotics, and chemical solutions
have been used to compensate these limitations, with interesting results being obtained.
Mouthwash used therapeutically is a complement to regular hygiene, brushing, and daily
flossing (7,8).
Control of the supragingival plate considerably increases when mouthwashes are used as
adjuvants to scaling and root planing, and they have a positive effect on subgingival bacterial
recolonization. Chlorhexidine is the gold standard for periodontal disease control, since it
inhibits plaque formation and is effective in preventing and controlling biofilm formation
(9,10).
Essential oils have also been shown to have antibacterial activity and antiplaque effect.
They have been used in candies and mouthwashes for years, the best known being Listerine®,
which is an essential oil product composed of a mixture of thymol, menthol and eucalyptol
combined with methyl salicylate and 26.9% alcohol and is available in different flavors
(11-14).
Miley et al. conducted a prospective, randomized, double-blind trial to evaluate the
efficacy of Smart Mouth Clinical dds mouthwash compared to 0.12% chlorhexidine and pla-
cebo mouthwash; their sample comprised 66 individuals randomized to receive any of the
study rinses (15). The measuring instruments used were gingival index, bleeding index, and
plaque index. Assessments were performed at 3 and 6 weeks. The results showed a significant
decrease at 3 and 6 weeks in all groups. Differences between groups were not statistically
significant. Clinical improvement was observed in all study groups.
Haerian et al. compared the antimicrobial effectiveness of three different mouthwashes.
Supragingival plaque samples were collected from 32 patients, which were placed on agar
plates and discs previously immersed in the three mouthwashes (16). The zone of bacterial
inhibition (zoi) was measured after incubation for 24 h. Moreover, in vivo effectiveness was
compared, and patients rinsed with 0.2% Chlorhexidine and Listerine® (for monotherapies);
the control group rinsed with water. The procedure was performed for 2 weeks and new
plaque samples were collected to count colony forming units (cfu). Haerian et al. concluded
that 0.2% chlorhexidine considerably reduces bacterial growth and that the three rinses
produce changes after 2 weeks, although with different degrees of effectiveness (16).
Garcia et al. conducted a prospective, randomized, double-blind trial comparing the
effectiveness of two mouthwashes based on chlorhexidine and cetylpyridinium chloride after
scaling and root planing (17). Their sample was comprised of 30 individuals and was divided
into 3 groups. The first group was administered 0.12% chlorhexidine and 0.05% cetylpyri-

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 Effectiveness of Chlorhexidine and Essential Oils Associated with Scaling and Root Planing

dinium chloride, the second group received 0.03% chlorhexidine and 0.05% cetylpyridinium
chloride, and the third one was the positive control group. All individuals were instructed
to rinse after scaling and root planing and improvement was assessed at the first month.
They concluded that rinsing with 0.12% chlorhexidine and 0.05% cetylpyridinium chloride
shows a higher effect in lowering the level of plaque as opposed to the other monotherapies.
Alshehri et al. conducted a systematic review to determine the effectiveness of essential
oils (Listerine) for improving periodontal status. Out of the 26 studies, only 13 support the
long-term effectiveness of Listerine during a 3–6 months period as a complement to scaling
and root planing. They concluded that essential oils provide an excellent anti-plaque effect
and reduce gingival inflammation as a complement to mechanical plaque control (14).
Vlachojannis et al. conducted a systematic review on the therapeutic benefits and safety
of Listerine®. In the review, they included the evaluation of the effect of mouthwash for 6
months and concluded that it is effective for the improvement of periodontal health (12).
The key to successful periodontal treatment is the absence of both inflammation and
destruction of the supporting tissues of the tooth. Often, scaling and root planing is not
sufficient for controlling the disease, but adjuvant therapies are an excellent complement
to mechanical plaque control. This study aims to evaluate two mouthwashes associated
with scaling and root planing and to compare their effectiveness in patients with chronic
periodontitis.

Materials and Methods

T his is an experimental, prospective, longitudinal, and analytical triple-blind study. The

study participants included patients of the Periodontics Department of the uladech Dental
Care Teaching Clinic, in Trujillo, from August to December 2015. The sample comprised 42
patients divided into three groups (18).
Inclusion criteria were patients between 30 and 50 years old, with no systemic disease,
periodontal pockets of ≥5 mm deep, and a minimum of 15 teeth.
Patients with prior periodontal treatment 5 months before initiation were excluded from
the study; smokers, alcoholics, and drug addicts of any condition as well as pregnant and
nursing women were also excluded.
This study was approved by the Dental School Ethics Committee of Universidad Católica
los Angeles de Chimbote, considering the principles of the Declaration of Helsinki and the
General Health Act of Peru (Act No. 268429) (19).
Since this was a triple-blind study, an operator labeled the containers with mouthwash as
mouthwash A and mouthwash B. To avoid the possibility of bias, this operator was responsible

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 Effectiveness of Chlorhexidine and Essential Oils Associated with Scaling and Root Planing

for disclosing the results at the end of the study. The type of mouthwash prescribed was not
revealed to the patients, statistician, and clinician.
The Hu-Friedy® who periodontal probe was used. Furthermore, to homogenize the sam-
ple, all patients were instructed in the bass brushing technique. oral b brand brushes and 90-g
triclosan-free Kolynos Herbal toothpaste were provided. All patients were summoned every
45 days to reinforce brushing instructions and to replenish their toothpaste. The sample was
divided into three groups with 14 individuals each.
• Group A: Scaling and root planing were performed and mouthwash A (0.12% chlorhex-
idine, 0.12% perioaid) was prescribed for 2 weeks.

• Group B: Scaling and root planing was performed and mouthwash B (essential oils,
Listerine®) was prescribed for 2 weeks.

• Group C: Only scaling and root planing was performed, and it was considered the control
group.
Indications for both mouthwashes were to rinse with 10 ml for 1 min, twice a day, in the
morning and at night after brushing, for 2 weeks.
Scaling and root planing was performed with Hu-Friedy® brand Grayce curettes: 1-2,
3-4, and 5-6 for anterior teeth and free surfaces, and 11-12 and 13-14 for distal and mesial
posterior teeth.
Teeth that met the inclusion criteria for depth upon probing (5 mm or more) were assessed
as in study initiation to observe clinical improvements. Probe depth was assessed by evaluat-
ing the distance in millimeters from the gingival margin to the base of the periodontal pocket
and gain in clinical insertion level was assessed by evaluating the distance in millimeters
from the enamel cement junction to the base of the periodontal pocket. Assessments were
long-term and were conducted at 3, 4, and 5 months.
The effectiveness of 0.12% chlorhexidine, essential oil, and the control group was com-
pared using Anova and Tukey’s test for multiple comparisons between treatments with a
level of significance of p < 0.05.

Results

T he values of periodontal status decrease, including probing depth (pd) and gain in clinical
insertion level (cil), are shown for the three analyzed therapies: 0.12% chlorhexidine,
essential oils, and scraping and root planing alone. The three therapies had a statistically
significant difference (p = 0.000) at 3, 4, and 5 months. Moreover, the probing depth values
at 3, 4, and 5 months were lower with 0.12% chlorhexidine than with essential oils and the
control group. Tukey’s test indicated that there was no difference between groups in terms

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 Effectiveness of Chlorhexidine and Essential Oils Associated with Scaling and Root Planing

of both initial probing depth measurements and clinical insertion level gain (A). However,
the essential oils group and the scraping and root planing group did not show differences
at 3, 4, and 5 months (B) but showed a significant difference from all the chlorhexidine
groups at 3, 4, and 5 months (Table 1).

Table 1. Comparison of the effectiveness of 0.12% chlorhexidine and essential oils associated with scaling and root
planing in the treatment of chronic periodontitis

Probing depth (pd) Clinical insertion level (cil)

3 4 5 3 4 5
Initial Initial
months months months months months months
Median 5.53 3.47 2.67 2.60 3.13 1.47 0.73 0.67
0.12%
SD 0.52 0.64 0.62 0.63 0.74 0.52 0.59 0.62
Chlorhexidine
Tukey A A A A A A A A
Median 5.57 4.57 4.57 4.07 3.07 2.71 2.79 2.79
Essential oils SD 0.51 0.51 0.51 0.73 0.73 0.47 0.43 0.47
Tukey A B B B A B B B
Median 5.57 4.57 4.50 3.86 3.21 2.29 2.29 1.86
Scaling and
SD 0.51 0.51 0.65 0.36 0.80 0.73 0.73 0.36
root planing
Tukey A B B B A B B B
F 0.027 18.937 47.899 25.980 0.125 17.423 47.330 41.516
Anova
p 0.974 0.000 0.000 0.000 0.883 0.000 0.000 0.000
Note. Patients who attended the Periodontics Department (n = 42).

The effectiveness of 0.12% chlorhexidine regarding initial status is associated with a

decrease in probing depth and a gain in the level of clinical insertion at 3, 4, and 5 months
(p < 0.05, in each case) (Table 2).

Table 2. Comparison of the effectiveness of 0.12% chlorhexidine associated with scaling and root planing in the treatment
of chronic periodontitis

Probing depth (pd) Clinical insertion level (cil)

3 4 5 3 4 5
Initial Initial
months months months months months months
Median 5.53 3.47   2.67   2.60   3.13 1.47   0.73   0.67  
SD 0.52 0.64   0.62   0.63   0.74 0.52   0.59   0.62  
Tukey Test 31.000 31.553 44.000 13.229 11.225 11.457
p 0.000 0.000 0.000 0.000 0.000 0.000
Note. Patients who attended the Periodontics Department (n = 42).

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The effectiveness of essential oils regarding initial status is associated with a decrease
in probing depth and a gain in the level of clinical insertion at 3, 4, and 5 months (p < 0.05,
in each case) (Table 3).

Table 3. Comparison of the effectiveness of essential oils associated with scaling and root planing in the treatment
of chronic periodontitis

Probing depth (pd) Clinical insertion level (cil)

3 4 5 3 4 5
Initial Initial
months months months months months months
Median 5.57 4.57   4.57   4.07   3.07 2.71   2.79   2.79  
SD 0.51 0.51   0.51   0.73   0.73 0.47   0.43   0.47  
Tukey Test 9.539 15.000 10.817 2.687 2.280 3.294
p 0.000 0.000 0.000 0.019 0.040 0.006
Note. Patients who attended the Periodontics Department (n = 42).

The initial status for scaling and root planing therapy alone is associated with a decrease
in probing depth and a gain in the level of clinical insertion at 3, 4, and 5 months (p < 0.05,
in each case) (Table 4).

Table 4. Evaluation of the periodontal status in a patient with scaling and root planing alone

Probing depth (pd) Clinical insertion level (cil)

3 4 5 3 4 5
Initial Initial
months months months months months months
Median 5.57 4.57   4.50   3.86   3.21 2.29   2.29   1.86  
SD 0.51 0.51   0.65   0.36   0.80 0.73   0.73   0.36  
Tukey Test 9.539 15.000 13.682 13.000 13.000 8.018
p 0.000 0.000 0.000 0.000 0.000 0.000
Note. Patients who attended the Periodontics Department (n = 42).

Discussion

S caling and root planing is a procedure by which plaque and calculi are removed from
supragingival and subgingival tooth surfaces; root planing, consequently, removes calculi
and adhered portions of residual cementum from the roots to create a smooth and clean
surface. This treatment restores periodontal health and completely removes the elements
that produce gingival inflammation; it also eliminates microorganisms and leads to a
change in subgingival plaque composition (20).

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In this study, 0.12% chlorhexidine and essential oils were chosen because of their
adjunctive effect on scaling and root planing in periodontal treatment and because they are
widely used in dentistry as monotherapies together with mechanical therapy for periodontal
treatment (21-23).
Periodontal destruction due to inflammation causes rupture of the connective tissue.
The greatest destruction in this process, however, is mediated by the host’s immune system.
Moreover, 0.12% chlorhexidine has a bactericidal effect and is the gold standard in peri-
odontal treatment (24).
For some time, periodontal treatment has been conducted only by mechanical methods.
However, since periodontal diseases appear to be specific infections caused by a proliferation of
a particular microbiological component and not of all the subgingival plaque species, it seems
logical that the flora can be eliminated in a biological and specific way with an antimicrobial
agent in association with a mechanical debridement of root surfaces (25-29).
This study demonstrated that the use of 0.12% chlorhexidine in association with scraping
and root planing achieved a significantly higher effectiveness compared to essential oils and
mechanical treatment of plaque alone (monotherapies) at 3, 4, and 5 months, thus constituting
an excellent therapeutic option.
Mouthwashes are often prescribed by dentists; however, a range of mouthwashes are
available over the counter and are used by patients without professional supervision. Like all
pharmacological substances, patients should consider not only their positive effects but also
their most relevant side effects and possible negative consequences (25-29).
The effectiveness of chlorhexidine in preventing initial plaque formation and disper-
sion of preformed plaque has made it the drug of choice for large clinical situations where
conventional daily oral hygiene techniques are difficult to perform. Therefore, they have
been used in cases where there is difficulty in performing proper hygiene as well as in ortho-
dontic treatments where adequate brushing is difficult and can easily lead to gingivitis and
periodontal involvement. Therefore, chlorhexidine can be used as an alternative method
for plaque control (30).
We concluded that 0.12% chlorhexidine in association with scaling and root planing was
more effective than essential oil monotherapies and mechanical plaque control alone at 3,
4, and 5 months after scaling and root planing.

Contribution of authors

Jhair Alexander León Rodríguez and Sandra Thays Vargas Casana: participated in the con-
ception and design of this paper, in the data analysis and interpretation processes, in the
drafting and critical review of this paper and in the approval of its final version.

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 Effectiveness of Chlorhexidine and Essential Oils Associated with Scaling and Root Planing

Pablo Alejandro Millones Gómez: participated in the data analysis and interpretation
processes, in the conception and design of this paper, and in the approval of its final version.

Conflict of Interest

N one declared.

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